Mercer County Community College Summer Sports Camps
Health History & Medical Authorization
for All Persons Under Age 18


Print this form.  Mail the signed, completed form and a completed registration form to:

Athletics Department
Mercer County Community College
P.O. Box 17202
Trenton, NJ 08690

This form must be completed and returned with the camp registration form. No camp registration will be processed unless accompanied by this medical form. NOTE: A doctor's signature is NOT required.

Camper's
Last Name
First Name
M___ F___
Middle Initial
Home Phone Camper's S.S. # Birthdate
Camp Names/Dates Applied for

Contacts & Phone Numbers

Mother's Name Daytime Phone Cell Phone
Father's Name Daytime Phone Cell Phone
Alternate
Emergency Contact
Daytime Phone Cell Phone
Family Physician Daytime Phone Cell Phone

Please complete the following:

If you answer YES, please explain on the back. Yes No
1. Currently under physician's care for:    
2. Current medications being taken:    
3. Were you ever advised not to allow this child to play in any sports?    
4. List any malfunction or loss of an organ:    
5. List any allergies including bee stings, hives, asthma, peanuts:    
6. Will your child need medication at camp?
If YES, please bring medication to the nurse on the first day your child attends camp.
   
7. Has this child...
a) had difficulty with sight?
   
b) had difficulty with hearing?
   
c) ever been unconscious after an injury?
   
d) had a fracture or dislocation within the last three years?
   
e) ever experienced high blood pressure?
   
f) ever experienced chest pain/palpitations?
   
g) had to stay in the hospital overnight within the last year?
   
h) other  (Please explain.)
   
8. Does this child have a history of...
a) fainting with exercise?
   
b) undue tiredness/fatigue?
   
c) a family member having sudden unexplained death under the age of 40?
   

According to state law, all campers must be immunized or submit a statement from a physician, prior to the first day of camp, that immunization is in progress.  (See NOTE below.)  Please indicate all immunization dates for each of the following:

Immunization List all dates
DPT (Diptheria, Pertussis, Tetanus) List all
four dates:
Last Td/Tetanus Booster  
Polio (OPV) List all
four dates:
MMR (Measles, Mumps, Rubella)  
Hepatitus  

If an emergency illness or injury occurs, I (parent/guardian) hereby authorize Mercer County Community College to treat and/or send this person to a physician or hospital and authorize the necessary treatment. I also authorize the physician or hospital to release my child after treatment to a representative of Mercer County Community College.

My hospital of choice is:
The Child's Medical Insurance Carrier:

All information on this form is complete, true and accurate to the best of my knowledge.

Signature of parent or guardian ________________________________________     Date _________________

NOTE
1. If there is a religious objection to immunization of a child, a written statement must be signed and submitted which states that the child is in good health and that you will assume full responsibility for his/her health while in camp.

2. If immunization is contraindicated for medical reasons, the parent or guardian shall submit to the camp a written statement signed by a licensed physician, indicating both the reason and length of the medical contraindication.

A completed copy of this form must be submitted with the camp registration form.

Questions? E-mail athlete@mccc.edu or call (609) 586-4800 ext. 3779.